Provider Demographics
NPI:1578758553
Name:JACKSONS POINT OF LIGHT FAMILY MEDICINE INC.
Entity Type:Organization
Organization Name:JACKSONS POINT OF LIGHT FAMILY MEDICINE INC.
Other - Org Name:JPL FAMILY MEDICINE, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATON/COO
Authorized Official - Prefix:MR
Authorized Official - First Name:DERRIC
Authorized Official - Middle Name:N
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-291-5255
Mailing Address - Street 1:PO BOX 1045
Mailing Address - Street 2:
Mailing Address - City:PHENIX CITY
Mailing Address - State:AL
Mailing Address - Zip Code:36868-1045
Mailing Address - Country:US
Mailing Address - Phone:334-291-5255
Mailing Address - Fax:877-395-0710
Practice Address - Street 1:1810 STADIUM DR
Practice Address - Street 2:SUITE 210
Practice Address - City:PHENIX CITY
Practice Address - State:AL
Practice Address - Zip Code:36867-3177
Practice Address - Country:US
Practice Address - Phone:334-291-5255
Practice Address - Fax:877-395-0710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA053082406BMedicaid
ALMD 26806OtherAL LICENSE
AL101067Medicaid
GA056705OtherGA LICENSE
GA056705OtherGA LICENSE